Page 81 - Fertility in Women with Rheumatoid Arthritis Vruchtbaarheid van vrouwen met reumatoïde artritis

immunity could play an important role in the early exhaustion of the primordial follicle pool. In RA, auto-antibodies like RF and anti-CCP can be found years before the disease becomes manifest.10 These auto-antibodies are thought to represent a subgroup of RA patients with most severe disease and the highest chance for extra- articular manifestations. Therefore, in case a decreased ovarian reserve might already be present early after diagnosis, it is most likely to be found in this subgroup of patients. The results of this study however, do not con rm the hypothesis of a decreased ovarian reserve at time of diagnosis in either anti-CCP or RF positive women.
Another possible explanation for early menopause is MTX, the rst choice drug for
newly diagnosed RA patients. Women with RA who want to become pregnant may
have been using MTX for a considerable amount of time. However, there is a lack
of studies on the effect of long term low-dose MTX treatment on ovarian reserve in
humans. In rats, daily administration of low (0.05 mg/kg) or high dose (0.15 mg/kg)
MTX for 20 days showed a dose dependent loss of vaginal cyclicity, and hormonal 5 changes towards post-menopausal values. Ovarian preantral and antral follicle
growth was reduced. This was already apparent in low dose MTX treatment and became even more distinct in rats that received higher doses.11 However, in our study, there was no effect of MTX on AMH levels, suggesting that short term MTX does not affect ovarian reserve. Further research is needed to elucidate the effect of long-term low-dose MTX treatment on fertility in women with RA. Unfortunately, the number of premenopausal women in the REACH with a follow up of one or more years is too small to study the long term effects of MTX treatment on fertility in this group.
In current study, detailed information on obstetric and gynecologic history was available for a limited number of patients. Since it is reported that serum AMH levels are not altered by use of hormonal contraception or parity, this is highly unlikely that these missing data would affect the outcome of this study.12,13 Timing of blood sampling in the menstrual cycle was not available, but it has been shown that serum AMH levels do not differ signi cantly throughout the menstrual cycle.14
In conclusion, the current study shows that AMH levels in RA patients are not influenced by disease activity and MTX use. Furthermore, the results do not con rm a reduced fertility based on a demise of the primordial follicle pool at time of diagnosis in women with RA, since the ovarian reserve, as measured by AMH levels, is comparable to the control group. Long term follow up of female RA patients should clarify the role of ovarian reserve and other clinical factors in subfertility in this patient group.
AMH in RA – early RA
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